'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system.

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

Experiences of trans patients in primary care settings: findings from The OutLook Study.

BACKGROUND: Relationships between primary care providers (PCP) and trans patients remain important, necessitating discussions about gender identity, health and their intersections. METHODS: Using an online survey, we explored socio-demographic and psycho-social factors associated with: (1) disclosing gender identity; (2) discussing gender identity-related health issues; and (3) comfort sharing gender identity with PCPs, among trans people (n =112) over 16years of age, sampled in Waterloo, Ontario, Canada. Bivariate and multivariate methods using modified Poisson regression generated effect estimates. RESULTS: Age, birth presumed gender, employment status, family support, and transphobia were significantly associated with disclosing gender identity, discussing gender identity-related health issues, and comfortability sharing gender identity with PCPs. CONCLUSION: Increasing PCPs' knowledge of trans-related health issues is stressed to improve access and quality for trans patients.

Transphobia rather than education predicts provider knowledge of transgender health care.

PURPOSE: Transgender and gender diverse (TGD) patients face significant hurdles in accessing affirming, knowledgeable care. Lack of provider knowledge presents a substantial barrier to both primary and transition-related care and may deter patients from seeking health care. Little is known about factors that affect provider knowledge or whether exposure to TGD health content during training is associated with improved knowledge among providers. Using the TGD Healthcare Knowledge Scale, this study aimed to determine whether prior education on TGD health predicts clinicians' current knowledge regarding health care for TGD patients. METHODS: An online survey examining exposure to TGD content and knowledge of TGD health care was distributed to all primary care providers in an integrated health care system in the Midwestern United States. Multivariable linear regression was used to predict provider knowledge, controlling for demographics, transphobia and other potential confounders. RESULTS: The response rate was 57.3% (n = 223). The mean knowledge score was 7.41 (SD = 1.31) on a 10-point scale. Almost half (48.4%, n = 108) had no formal education on TGD health care, yet half (49.7%, n = 111) of providers reported previously caring for at least one transgender patient. In regression analysis, provider knowledge of TGD health care was associated with transphobia (ß = -0.377, 95% CI = -0.559 to -0.194, p < 0.001), but not with hours of formal education (ß = -0.027, 95% CI = -0.077 to 0.023, p = 0.292) or informal education (ß = -0.012, 95% CI = -0.033 to 0.009, p = 0.259). CONCLUSIONS: Increasing hours of education related to TGD health care may not be sufficient to improve providers' competence in care for TGD individuals. Transphobia may be a barrier to learning that needs to be addressed. Broader efforts to address transphobia in society in general, and in medical education in particular, may be required to improve the quality of medical care for TGD patients.

Primary Care Clinicians' Willingness to Care for Transgender Patients.

Transgender patients report negative experiences in health care settings, but little is known about clinicians' willingness to see transgender patients. We surveyed 308 primary care clinicians in an integrated Midwest health system and 53% responded. Most respondents were willing to provide routine care to transgender patients (85.7%) and Papanicolaou (Pap) tests (78.6%) to transgender men. Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia. Medical education should address professional and personal factors related to caring for the transgender population to increase access.

Frequent Experience of LGBQ Microaggression on Campus Associated With Smoking Among Sexual Minority College Students.

Introduction: Lesbian, gay, bisexual, or queer/questioning (LGBQ) microaggressions refer to often-unintentional insults, assaults, and invalidations that denigrate sexual minorities. While experiencing hostile discrimination and violence has previously been associated with elevated rates of smoking cigarettes for LGBQ college students, the relationship between LGBQ microaggressions and smoking is unknown. Methods: Data from a national anonymous online survey of sexual and gender minority college students were used to examine the relationship between past month cigarette smoking and interpersonal LGBQ microaggressions. Multivariable logistic regression assessed the relationship between smoking and frequent (chronic) experiences of microaggressions, using a hierarchical procedure to control for demographics, predictors of smoking, and academic factors. Results: Past year frequent LGBQ microaggression was reported by 48% of respondents and was more common among students who smoked in past 30 days. Experiencing past year physical violence was reported by 15% and did not differ by smoking status. Past year frequent experience of microaggressions was associated with increased odds of 1.72 (95% CI 1.03-2.87) for past 30-day smoking after adjusting for age, gender, race, socioeconomic indicators, alcohol misuse, physical violence, as well as academic stress and engagement. Conclusions: The results indicate that frequently experiencing LGBQ microaggressions is a risk factor for LGBQ college students smoking cigarettes. The mechanisms underlying this relationship require additional research, as does identifying positive coping strategies and institutional strategies to address LGBQ microaggressions on campuses. Tobacco control efforts should consider the impact of microaggression on the social environment for the prevention and treatment of tobacco use among LGBQ individuals. Implications: Microaggressions related to sexual minority identity include subtle forms of discrimination experienced during daily interactions that can create hostile and stressful social environments for a socially disadvantaged group. Prior research has demonstrated that LGBQ college students have higher rates of cigarette smoking, and that experiencing identity-based violence is a risk factor. This study revealed that experiencing frequent LGBQ microaggressions on college campus is associated with increased likelihood of current smoking among LGBQ college students.

Primary care providers' willingness to continue gender-affirming hormone therapy for transgender patients.

Background: Most transgender individuals either use or are interested in using gender-affirming hormone therapy (HT). Making gender-affirming HT available in primary care is critical for quality care to this vulnerable population. The barriers that transgender patients experience to accessing this treatment may be exacerbated if primary care providers (PCPs) will not provide it. Little is known about PCPs' willingness to administer HT to transgender patients. Objective: To examine whether PCPs are willing to continue prescribing HT for transgender patients and the factors that predict such willingness. Methods: An online survey of internal and family medicine physicians and residents practising in a large integrated Midwest health system (n = 308); 158 responded to the relevant questions (51.3%). Results: Approximately 50% of respondents were willing to continue HT for transgender patients. Most participants had previously met a transgender person (77%), and approximately half of them had cared for a transgender patient in the past 5 years. Multivariate logistic regression results indicate that attending physicians had lower odds of willingness to continue HT compared with medical residents, and those who reported perceived capability of providing routine care to transgender patients had higher odds of willingness. Conclusions: Only about half of PCPs surveyed were willing to continue HT for transgender patients. Our study indicates that both personal and clinical factors play a role. Future research should address ways to increase PCPs' willingness and comfort related to continuing HT for transgender patients.

Ecological Covariates of Subtle and Blatant Heterosexist Discrimination Among LGBQ College Students.

Sexual minority college students report experiencing interpersonal heterosexism, ranging from subtle insults to blatant physical violence. Such negative experiences can complicate developmental tasks common to adolescence and emerging adulthood. Studies examining the nature of heterosexism on college campuses have focused on blatant manifestations, yet subtle forms are more prevalent. Guided by ecological theory, we investigate the microsystem (e.g., perceived social support from friends, ambient heterosexism on campus), mesosystem (e.g., interaction between social support and ambient heterosexism), and macrosystem level (e.g., knowledge of gay-straight alliances on campus) covariates of interpersonal microaggressions, avoidance behaviors, verbal threats, and physical threats. Participants consisted of 530 self-identified LGBQ college students from 37 states. Regression results suggest that at the microsystem level, ambient heterosexism was positively associated with interpersonal microaggressions, avoidance behaviors, and verbal threats. At the mesosystem level, perceptions of LGBQ student support within one's institution moderated the effects of ambient heterosexism on three types of interpersonal heterosexism. At the macrosystem level, students who reported knowing that their campus had a sexual-orientation inclusive anti-discrimination policy reported encountering fewer verbal threats. Directions for future research and implications for campus programming are discussed.

Academic and social integration on campus among sexual minority students: the impacts of psychological and experiential campus climate.

A heterosexist campus climate can increase risk for mental health problems for sexual minority students; however, the relationship between campus climate for sexual minorities and academic outcomes remains understudied. Using a sample of sexual minority respondents extracted from a campus climate survey conducted at a large university in the Midwest, we examine relationships between multiple dimensions of psychological and experiential campus climate for sexual minorities with academic integration (academic disengagement, grade-point average [GPA]) and social integration (institutional satisfaction, acceptance on campus). We also investigate the protective role of engagement with informal academic and peer-group systems. Findings suggest campus climate affects sexual minority students' integration. In multivariate analyses, perceptions of whether lesbian, gay, and bisexual (LGB) people could be open about their sexual identity was positively associated with acceptance on campus; personal heterosexist harassment was positively associated with academic disengagement and negatively with GPA. Students' informal academic integration (instructor relations) and informal social integration (LGB friends) demonstrated influential main effects but did not moderate any of the climate-outcome relationships. Researchers should further explore the relationships between climate and academic outcomes among sexual minority students, both collectively and among specific sub-groups, and address the role of other protective factors.

Discrimination and depressive symptoms among sexual minority youth: is gay-affirming religious affiliation a protective factor?

Researchers have examined perceived discrimination as a risk factor for depression among sexual minorities; however, the role of religion as a protective factor is under-investigated, especially among sexual minority youth. Drawing on a cross-sectional study investigating campus climate at a large public university in the U.S. midwest, we examined the role of affiliation with a gay-affirming denomination (i.e., endorsing same-sex marriage) as a moderating factor in the discrimination-depression relationship among self-identified sexual minority (n = 393) and heterosexual youth (n = 1,727). Using multivariate linear regression analysis, religious affiliation was found to moderate the discrimination-depression relationship among sexual minorities. Specifically, the results indicated that the harmful effects of discrimination among sexual minority youth affiliated with denominations that endorsed same-sex marriage were significantly less than those among peers who affiliated with denominations opposing same-sex marriage or who identified as secular. In contrast, religious affiliation with gay-affirming denominations did not moderate the discrimination-depression relationship among heterosexual participants. The findings suggest that, although religion and same-sex sexuality are often seen as incompatible topics, it is important when working with sexual minority clients for clinicians to assess religious affiliation, as it could be either a risk or a protective factor, depending on the religious group's stance toward same-sex sexuality. To promote the well-being of sexual minority youth affiliated with denominations opposed to same-sex marriage, the results suggest these faith communities may be encouraged to reconsider their position and/or identify ways to foster youth's resilience to interpersonal discrimination.

Correlates of HIV testing uptake among kothi-identified men who have sex with men in public sex environments in Chennai, India.

Kothi-identified men who have sex with men in India are highly marginalized and are at high-risk for HIV. This study examines HIV testing among 132 self-reported HIV-negative and unknown serostatus kothis recruited from public sex environments in Chennai, India. Using logistic regression we identified variables associated with HIV testing uptake (i.e., being tested and knowing the result). Sixty-one percent reported HIV testing uptake. At the bivariate level, married men, those with low HIV transmission knowledge, those who engaged in unprotected anal sex and unprotected receptive anal sex were at lower odds of reporting testing uptake. In multivariate analysis, married men and those with low levels of HIV transmission knowledge were at decreased odds of being tested, as were kothis who experienced forced sex. Culturally competent programs engaging married kothis are needed. Interventions to facilitate HIV prevention education and systemic interventions to combat sexual violence may facilitate HIV testing uptake among kothis.

Qualitative research with small connected communities: generating new knowledge while upholding research ethics.

Qualitative researchers have a dual mission: to generate knowledge through rigorous research and to uphold ethical standards and principles. Qualitative researchers often conduct studies with small connected communities in which relationships exist among community members. When engaging such communities, researchers might face ethical issues in upholding confidentiality standards while they work to achieve their dual mandate. Qualitative scholars have paid little attention to the ethical challenges that might arise in this context. Drawing on our experiences conducting studies with such communities, we expand the dialogue concerning qualitative research ethics by making explicit conceptual and practical tensions that emerge at various stages of the research process; articulating our respective reflective processes; and exploring issues associated with strategies for upholding confidentiality. We conclude with lessons learned to guide researchers who might face similar challenges.

Gynecological Providers' Willingness to Prescribe Gender-Affirming Hormone Therapy for Transgender Patients.

Purpose: Transgender individuals face barriers to accessing gender-affirming hormone therapy, yet little is known about gynecological providers' willingness to provide such care. Methods: We surveyed gynecological providers in one healthcare system to determine their willingness to prescribe hormone therapy (HT) for transgender patients and factors associated with willingness to both initiate and refill HT. Results: Among respondents (N = 60), 60.3% and 27.6% were willing to refill and initiate HT for transgender patients, respectively. Willingness to refill HT was associated with having met a transgender person and lower transphobia. Unwillingness was associated with lack of transgender health training, lack of staff knowledge about transgender health, and unfamiliarity with transition guidelines. Willingness to initiate HT was associated with younger age and resident status. Unwillingness was associated with unfamiliarity with transition guidelines. Conclusion: While gynecological providers are qualified to prescribe HT for transgender patients, willingness to do so may be influenced by both personal and educational/training factors. Encouraging and training gynecological providers to provide gender-affirming HT will help to increase access for transgender individuals.

Overlooked and Invisible: Everyday Experiences of Microaggressions for LGBTQ Adolescents.

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents face a number of challenges in their lives related to heterosexism and cissexism. Drawing on the microaggressions framework, we conducted two focus groups with LGBTQ adolescents (n = 11; ages 14-18, six trans/genderfluid, one person of color) to (1) explore the type and nature of microaggressions experienced by LGBTQ adolescents; (2) assess the relevance of existing LGBTQ microaggression taxonomies for this group; and (3) understand the impact of microaggressions on LGBTQ adolescents. Participants' experiences of microaggressions reflected complex forms of discrimination emerging from the intersections of sexual and gender identity.

Gynecologic Health Care Providers' Willingness to Provide Routine Care and Papanicolaou Tests for Transmasculine Individuals.

Background: Transmasculine individuals who have a cervix may be at risk of cervical cancer, but they face a number of barriers to accessing care, including difficulty finding knowledgable and culturally sensitive providers who are willing to care for transgender patients. We examined gynecologic health care providers' willingness to provide routine care and Papanicolaou tests (Pap tests) to transmasculine individuals, including the role of personal, clinical, and professional factors. Materials and Methods: We surveyed attending physicians, advanced practitioners, and residents in the Women's Health department of a large, integrated Midwest health system (n = 60, 74.1% response rate). Results: A majority of participants were female (68.3%) and white (73.3%). Most had met a transgender person before (79.7%), and 40.7% had cared for a transgender patient in the past 5 years. Most reported willingness to provide routine care (74.6%) and Pap tests (85.0%) to transmasculine people. Bivariate analysis suggests that having met a transgender person (p = 0.028), higher empathy scores (p = 0.015), political views (p = 0.0130), and lower transphobia (p = 0.012) were associated with willingness to provide routine care to transmasculine individuals. Lower transphobia (p = 0.034) and political views (p < 0.001) were also associated with willingness to provide Pap tests to transmasculine people. Conclusions: Providers' willingness was not associated with barriers related to training or knowledge-only with personal biases and experiences. Transgender-inclusive health care training that addresses personal attitudes should be a routine part of training for all health professionals.

Hearing "That's So Gay" and "No Homo" on Campus and Substance Use Among Sexual Minority College Students.

Sexual orientation microaggressions are common on college campuses and can contribute to negative outcomes; yet little is known about their relationship with substance use outcomes. Among a convenience sample of cisgender sexual minority college students (n= 574; 57.0% female, 24.9% people of color, 50.7% gay/lesbian; 72.4% public school) from 37 states (67.8% Midwest), this analysis investigates the association between hearing "that's so gay" and "no homo" on campus and hazardous alcohol use and the frequency of illicit drug use. Using multivariable regression analyses, the commonly heard phrases "that's so gay" and "no homo" were each found to significantly increase the risk for hazardous drinking and the frequency of drug use among students. Efforts should be made to create more welcoming campus climates for sexual minority students by reducing the use of these microaggressions and, in the meantime, offering supports to mitigate their harmful effects.

Advancing Research on LGBTQ Microaggressions: A Psychometric Scoping Review of Measures.

Understanding the nature and consequences of LGBTQ microaggressions is critical to fostering equity and wellbeing among sexual and gender minorities. Yet little guidance is available for researchers seeking psychometrically robust measures of subtle LGBTQ slights, invalidations, and insults. To address this gap, we conducted a scoping review of multi-item quantitative measures that included at least one question addressing LGBTQ microaggressions. This article reports the study characteristics and psychometric properties of 27 original measures we identified and their subsequent adaptations. The article concludes with an assessment of strengths and limitations of LGBTQ microaggression measurement, highlighting aspects of measurement innovation on which future researchers can build. As microaggressions remain a powerful and underexplored mechanism of sexual and gender minority oppression, this review will help to both advance methodological quality in this critical research area and enhance our understanding of how microaggressions manifest in the lives of LGBTQ individuals.

Heterosexism, Depression, and Campus Engagement Among LGBTQ College Students: Intersectional Differences and Opportunities for Healing.

LGBTQ people experience health disparities related to multilevel processes of sexual and gender marginalization, and intersections with racism can compound these challenges for LGBTQ people of color. Although community engagement may be protective for mental health broadly and for LGBTQ communities in buffering against heterosexism, little research has been conducted on the racialized dynamics of these processes among LGBTQ communities. This study analyzes cross-sectional survey data collected among a diverse sample of LGBTQ college students (n = 460), which was split by racial status. Linear regression models were used to test main effects of interpersonal heterosexism and engagement with campus organizations on depression, as well as moderating effects of campus engagement. For White LGBTQ students, engaging in student leadership appears to weaken the heterosexism-depression link-specifically, the experience of interpersonal microaggressions. For LGBTQ students of color, engaging in LGBTQ-specific spaces can strengthen the association between sexual orientation victimization and depression.

Does Closeness to Someone Who Is Gay, Lesbian, or Bisexual Influence Etiology Beliefs About Homosexuality?

Research suggests that contact with sexual minorities and etiology beliefs regarding the origins of homosexuality are associated with antigay bias; however, factors related to etiology beliefs have received little empirical attention. Our primary research question is: Does closeness to someone who is gay, lesbian, or bisexual influence etiology beliefs? Students (n = 851) from four U.S. universities completed an anonymous survey, and regression results indicated that contact and closeness were not significantly associated with etiology beliefs. Because both contact and relationship closeness were associated with antigay attitudes, and closeness demonstrated the largest effect, we tested three alternative structural equation models to determine if contact and closeness mediated etiology beliefs. Results suggested that contact and the degree of closeness are indirectly associated with students' etiology beliefs through antigay bias.

Barriers and facilitators to voluntary HIV testing uptake among communities at high risk of HIV exposure in Chennai, India.

In India, increasing uptake of voluntary HIV testing among 'core risk groups' is a national public health priority. While HIV testing uptake has been studied among key populations in India, limited information is available on multi-level barriers and facilitators to HIV testing, and experiences with free, publicly available testing services, among key populations. We conducted 12 focus groups (n = 84) and 12 key informant interviews to explore these topics among men who have sex with men, transgender women, cisgender female sex workers, and injecting drug users in the city of Chennai. We identified inter-related barriers at social-structural, health-care system, interpersonal, and individual levels. Barriers included HIV stigma, marginalised-group stigma, discrimination in health-care settings, including government testing centres, and fears of adverse social consequences of testing HIV positive. Facilitators included outreach programmes operated by community-based/non-governmental organisations, accurate HIV knowledge and risk perception for HIV, and access to drug dependence treatment for injecting drug users. Promoting HIV testing among these key populations requires interventions at several levels: reducing HIV-related and marginalised-group stigma, addressing the fears of consequences of testing, promoting pro-testing peer and social norms, providing options for rapid and non-blood-based HIV tests, and ensuring non-judgmental and culturally competent HIV counselling and testing services.

Graduate Social Work Faculty's Support for Educational Content on Women and on Sexism.

Social work faculty play an important role in preparing students to address sexism and engage in culturally competent practice with women. This study examines the nature of U.S. and Anglo-Canadian graduate social work faculty's support for content on women and on sexism. Although support appears high for both content areas, results suggest that faculty endorsement for content on women is significantly greater than that for sexism. Further, bivariate and multivariate analyses indicate that the nature of support differs for each content area. Implications for social work education are discussed.